Match each of the following end-of-life clinical scenarios involving conflicts in decision-making to the most appropriate legal or ethical resolution.
- A 71-year-old man with advanced hepatic encephalopathy lacks capacity. His designated healthcare proxy (his brother) demands placement of a percutaneous feeding tube, but the patient's previously executed, legally valid living will explicitly declines artificial nutrition in a terminal state.Adhere to the explicit stipulations in the patient's living will, which supersede the proxy's contradictory demands.
- An 82-year-old woman with a massive ischemic stroke is comatose. She has no written advance directive and did not designate a proxy. Her husband of 40 years requests a transition to comfort measures, while her two adult daughters threaten a lawsuit if artificial nutrition is stopped.Follow the directives of the spouse, who holds legal priority in the default surrogate hierarchy.
- A 68-year-old man with amyotrophic lateral sclerosis is hospitalized for acute respiratory failure. He is fully alert and clearly communicates via an eye-tracking device that he wishes to be extubated and declines further interventions, though his wife begs the team to keep him on the ventilator.Honor the patient's contemporaneous autonomous request to withdraw life-sustaining therapy.
- A 75-year-old man with severe Lewy body dementia presents with septic shock. He has no known family or friends, no advance directive, and no designated proxy. The clinical team determines that escalating vasopressor support is medically non-beneficial and wishes to transition to comfort care.Consult the hospital ethics committee or seek court-appointed guardianship before altering the care plan.
Answer
The correct pairings align the patient's specific clinical scenario with the governing ethical or legal principle: living wills override conflicting proxies; spouses outrank adult children in surrogate hierarchies; a capacitated patient's autonomy overrides family wishes; and unrepresented patients require institutional or legal safeguards before withdrawing care.
Each scenario illustrates a distinct, highly-tested conflict in end-of-life ethics. The correct pairings appropriately apply the hierarchy of decision-making: (1) Capacitated patient's current wishes, (2) Patient's prior written wishes (Living Will), (3) Designated Proxy using substituted judgment, (4) Default legal surrogate hierarchy (Spouse prioritized), and (5) Ethics/Court intervention for unrepresented patients.
Step-by-Step Solution
Key Concept
Ethical and Legal Frameworks in Surrogate Decision-Making